The Latest Guidelines for Prostate Cancer Screening

Female doctor talking with patient.

This blog has been updated to reflect the U.S. Preventive Services 2018 Final Prostate Cancer Screening Guidelines.

Today the United States Preventive Services Task Force released its final guidelines for prostate cancer screening. The release of cancer screening guidelines like these, especially for prostate cancer, always generate a lot of headlines and also controversy. But just how different are the new guidelines from the previous recommendations? Here is everything you need to know about what is actually going on.

First, a little background.

Prostate cancer screening has been a controversial topic since a prostate cancer test was first approved by the FDA in the 1990s. It made a big splash in the news last year when the task force released its draft guidelines and in the previous year when Ben Stiller announced his battle with prostate cancer. I wrote about it then as well.

The prostate-specific antigen (or PSA) test is a blood test that looks for a protein made by prostate cells. If the levels are high, that means that something could be going on in the prostate that causes this protein to leak out into the blood. It could be cancer, but it could also be the result of a benign condition like inflammation or prostate enlargement. The trouble is that the test can’t tell you the difference between inflammation and cancer, and it also can’t tell the difference between a type of cancer that will never cause any harm and one that will.

Today the U.S. Preventive Services Task Force, the government-sponsored panel of independent clinicians that reviews and issues recommendations on measures to prevent disease, put out their new 2018 final recommendation. This version is virtually the same as the draft recommendations, but, importantly, it’s different than the task force’s 2012 final recommendation that your doctor has been following.

So, what’s changed since 2012? That year, the task force recommended against the PSA test for all men. In the new guidelines, the task force says that men 55 to 69 years of age, regardless of risk factors (like family history), should discuss the harms and benefits of prostate cancer screening with their physician, weighing their specific health circumstances and their values in the decision of whether to be screened or not. For men 70 and up, the task force still recommends that they not get the PSA test, because the risks outweigh the benefits. This would essentially bring the task force recommendations in line with those of the Urological Association of America and the American Cancer Society, which both recommend against routine screening, but do recommend discussing the risks and benefits of the test with your doctor.

So, why is the task force making this change now? Well, previously it was against screening because the data suggested that the risks outweighed the benefits.  Specifically, according to the task force in 2012: For every 1,000 people screened, we will save up to one life — that’s a good thing — but among those 1,000 people, 30 to 40 will develop erectile dysfunction or urinary incontinence, two will have a heart attack, and one will develop a serious blood clot due to treatment. They also say that for every 3,000 that are screened, one man will also die from a complication of the surgery.

Now, based on the most recent studies — including a big study from Europe, which showed a benefit to screening — the task force has revised the numbers. They calculate that for every 1,000 people screened an extra life will be saved, for a total of about one to two, which is good, but there are still very significant risks of screening.

According to the task force, for every 1,000 men screened, about 240 will get a positive result followed by a biopsy. Unfortunately, many of these will be false positives, and biopsies can have side effects, like pain, bleeding, and infection, as well as psychological distress. Of the 240 men with a positive result on the PSA test, 100 will have a positive biopsy, but somewhere between 20 to 50 percent of these men will have a type of cancer that would never harm them. Since the test can’t tell the difference between a harmful type of cancer and one that won’t harm you, it is pretty difficult for most men to do nothing, so about 80 of the 100 will have surgery or radiation, which will lead to an average of three men avoiding metastatic disease and the one to two we mentioned before avoiding death from the cancer. At the same time, 60 or more men will have a serious complication from an intervention, like incontinence or sexual dysfunction.

So, while it appears that not too much has really changed in the final evaluation, the shift in the proposal from advising clinicians to recommend against the test, to discussing it is a significant one and is likely to be met with a lot of pushback from physicians who are concerned about the dangers of over-screening.

What You Should Do Now 

First, don’t think that the new guideline is a recommendation to get the test. Everyone agrees that there are serious risks to PSA screening and you need to be fully informed about them, as well as the benefits, before deciding what to do.  Getting the test can give you some information, but you have to know how to use it. Everyone will react differently to the information, so deciding if you are going to have the test is a very personal decision. If you are concerned about prostate cancer, talk with your doctor and together you can decide what the best decision is for you. Remember it’s important to discuss up front what the next steps are if you have a positive or negative test result, and what you would want to do because once you see a result, you can’t unsee it.

You may have noticed that the task force has the same recommendation for those at “normal risk” and those at higher risk for prostate cancer, such as African Americans and people with a family history. That’s because, according to the task force, there isn’t enough data to make separate recommendations for higher risk groups. If you fall into one of these groups you will want to take that into consideration when discussing screening with your physician.

If you do decide to get a PSA test, and the results are elevated, your doctor may want to do further testing. Remember, an elevated PSA doesn’t necessarily mean that you have aggressive prostate cancer, and you want to discuss all of the risk and benefits of next steps. If it turns out you do have prostate cancer, don’t panic. Prostate cancer is typically a very slow-growing tumor. Also, while prostate cancer is pretty common — 13 percent of men get it — most don’t die from it.

In September 2017, a study published in the New England Journal of Medicine found that there was no significant difference in mortality among men with prostate cancer who either had had surgery or radiation and those who had only been monitored, with no intervention.  While the disease was slightly more likely to progress in men who were simply followed, the researchers found that they would have to operate on 30 men to prevent one man from having the metastatic disease after 10 years.  So, active surveillance can be an excellent option to discuss with your doctor.

How to Reduce Your Risk 

There are a lot of studies looking at how to reduce prostate cancer risk and some of the best data is around lifestyle. The best way to reduce your risk is to:

  • Eat more fruits and vegetables
  • Eat less meat and dairy
  • Eat foods rich in omega-3s
  • Eat whole grains
  • Eat less refined carbohydrates
  • Exercise: Shoot for 150 minutes weekly